Citation Nr: 18108887 Decision Date: 06/06/18 Archive Date: 06/06/18 DOCKET NO. 13-17 472 DATE: June 6, 2018 ORDER Entitlement to service connection for tinnitus is granted. Entitlement to service connection for pleural thickening and pleural plaques due to asbestos exposure is granted. Entitlement to service connection for hypertension is granted. Entitlement to service connection for genital warts is granted. Entitlement to a rating in excess of 60 percent for cluster headaches, on an extraschedular basis, is denied. REMANDED Entitlement to service connection for a back condition with arthritis is remanded. Entitlement to service connection for a left knee condition with arthritis is remanded. Entitlement to service connection for a left ankle condition is remanded. Entitlement to service connection for a left eye condition, to include a visual scotoma, is remanded. Entitlement to service connection for vertigo is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for a sciatic nerve condition is remanded. Entitlement to a compensable rating for calcific tendinitis of the right knee is remanded. Entitlement to an initial rating in excess of 30 percent from June 27, 2014 to May 16, 2017, and in excess of 70 percent from May 17, 2017 to May 6, 2016, for an acquired psychiatric disorder is remanded. Entitlement to an effective date prior to May 7, 2016 for the grant of a 100 percent evaluation for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his tinnitus began during active service. 2. Resolving reasonable doubt in the Veteran’s favor, his pleural thickening and pleural plaques are related to his in-service asbestos exposure. 3. Resolving reasonable doubt in the Veteran’s favor, his hypertension manifested to a compensable degree within one year of his separation from service and is not attributable to intercurrent causes. 4. The Veteran’s genital warts began during active service. 5. For the entire period on appeal, the Veteran’s cluster headaches have not resulted in an “average impairment in earning capacity” significant enough to warrant more than an additional 10 percent extraschedular rating in excess of his 50 percent schedular rating. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for service connection for pleural thickening and pleural plaques are met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for entitlement to service connection for hypertension are met. 38 U.S.C. §§ 1112, 1113, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a). 4. The criteria for service connection for genital warts are met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 5. The criteria for an evaluation in excess of 60 percent, including an extraschedular evaluation in excess of 10 percent, for service-connected cluster headaches are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.124(a), Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from July 1986 to March 1990. The Board notes that the December 2016 Board decision noted the Veteran’s September 2015 statement disagreeing with the evaluation assigned for his acquired psychiatric disorder. The Board noted that this was not a valid notice of disagreement (NOD) because it was not submitted on a VA Form 21-0958 or submitted prior to March 24, 2015. However, the December 2016 Board decision failed to discuss a statement labeled as an NOD with the initial rating assigned for the Veteran’s psychiatric disorder and received by VA on March 6, 2015. Although this was not submitted on a VA Form 21-0958, it was received by VA before that requirement took place. As such, it is a valid NOD with the initial evaluation assigned for the Veteran’s psychiatric disorder in the February 2015 rating decision. Despite this NOD, no statement of the case (SOC) has been issued for the initial increased rating issue, nor is there any other evidence of appeal action being taken on this issue. As such, it must be remanded for the issuance of an SOC. See Manlincon v. West, 12 Vet. App. 238 (1999). Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (noting that nexus may be demonstrated by a showing of continuity of symptomatology where the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a)). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. As to asbestos-related diseases, the Board notes there are no laws or regulations specifically dealing with asbestos and service connection. However, the VA Adjudication Procedure Manual (M21-1 MR), case law, and VA General Counsel opinions provide guidance in adjudicating these claims. In 1988, VA issued a circular on asbestos-related diseases providing guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans’ Administration, DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular since have been included in VA Adjudication Procedure Manual, M21-1 MR, part VI, Subpart ii, Chapter 2, Section C (December 13, 2005). The M21-1 MR provides the following non- exclusive list of asbestos related diseases/abnormalities: asbestosis, interstitial pulmonary fibrosis, tumors, effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, bronchial cancer, cancer of the larynx, cancer of the pharynx, cancer of the urogenital system (except the prostate), and cancers of the gastrointestinal tract. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9(b). The M21-1 MR also provides the following non-exclusive list of occupations that have higher incidents of asbestos exposure: mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, and manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9(f). The M21-1 MR also provides that a clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. Symptoms and signs include dyspnea on exertion, end-respiratory rales over the lower lobes, compensatory emphysema, clubbing of the fingers at late stages, and pulmonary function impairment and cor pulmonale that can be demonstrated by instrumental methods. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9(e). 1. Entitlement to service connection for tinnitus The Veteran asserts that his tinnitus symptoms began in service and that they have continued since that time. Therefore, he believes that service connection is warranted. With regard to a present disability, May 2015 and November 2015 VA examinations diagnosed the Veteran with bilateral tinnitus. The first element of Shedden/Caluza is met. With regard to an in-service event, the Veteran’s service treatment records are negative for any reports of tinnitus. However, the Veteran has reported that he first experienced humming in his ears during boot camp. The Board finds these reports of in-service tinnitus symptoms to be credible as the Veteran has consistently reported such symptoms and his reports are not contradicted by anything in the record. The second element of Shedden/Caluza is also met. The remaining question is whether there is a medical nexus between the Veteran’s in-service tinnitus and his current tinnitus. As noted above, the Veteran was afforded VA audiological examinations in May 2015 and November 2015. Both examiners noted the Veteran’s reports of in-service onset, but concluded that his tinnitus was not documented in his service treatment records. The Board notes that this lack of evidence is not negative evidence and that corroborating documentation is not required to establish in-service onset. As the examiners’ opinions are based on inaccurate premises, the Board finds that they are of limited probative value. The remaining medical evidence relating to the Veteran’s audiological disabilities is negative for any opinions on the etiology of his tinnitus. The Board has considered remanding the claim to address the deficiencies in the May 2015 and November 2015 VA examinations. However, as the Veteran has provided credible and competent statements reporting the onset of tinnitus symptoms in service and continuous symptoms since that time, the Board finds that the evidence is, at minimum, in equipoise regarding the question of whether the Veteran’s current tinnitus is related to his military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. The benefit of the doubt will be conferred in the Veteran’s favor, and remand is not necessary. The service-connection claim for tinnitus is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to service connection for a lung condition due to asbestos exposure The Veteran asserts that he currently suffers from pleural plaques that are the result of in-service asbestos exposure. Specifically, he claims that he was exposed to asbestos fibers while serving on Navy ships. Therefore, he believes that service connection is warranted. With regard to a present disability, an April 2016 chest x-ray showed diffuse bilateral pleural thickening that may represent pleural plaque formation. The first element of Shedden/Caluza is met. With regard to an in-service event, the Veteran’s service treatment records are negative for any respiratory complaints. His personnel records are also negative for any definitive asbestos exposure. However, he has submitted a statement from a fellow servicemember that supported his contentions of in-service asbestos exposure. Additionally, his post-service work as a corrections officer is not consistent with asbestos exposure. In light of the Veteran’s consistent reports of in-service asbestos exposure, corroborating statement from his fellow servicemember, and lack of other likely post-service sources of asbestos exposure, the Board finds that in-service asbestos exposure can be conceded. The second element of Shedden/Caluza is also met. The remaining question is whether there is a medical nexus between the Veteran’s conceded in-service asbestos exposure and currently diagnosed pleural thickening and possible pleural plaques. The Veteran was afforded a VA examination in April 2016 with an August 2016 addendum opinion. The April 2016 examiner noted the findings of bilateral pleural thickening on the April 2016 x-ray but concluded that, without findings of pleural plaques or calcifications, there was no confirmed diagnosis of asbestosis. He also noted that a March 2016 chest x-ray was normal. The August 2016 addendum reiterated that there was no definitive diagnosis of pleural plaques to support the Veteran’s claim. A September 2016 addendum report of the March 2016 chest x-ray found that there was evidence of mild pleural thickening in the left costophrenic angle. The lack of consideration of this finding by the April and August 2016 examiner limits the probative value of his opinion, as it relies in part on the lack of x-ray findings prior to April 2016. The opinion’s probative value is further diminished by the lack of consideration of the September 1994 VA treatment record noting that the Veteran’s chest x-ray findings at that time were distinctly abnormal for his age. Moreover, the examiner’s requirement that the Veteran’s lung findings be definitively shown to be asbestosis or due to asbestos exposure is a stricter standard that is required by VA regulations. The Board has considered remanding this claim for a new VA examination that addresses the deficiencies of the April 2016 VA examination and August 2016 addendum opinion. However, as the evidence appears to show that it is at least as likely as not that the Veteran has an asbestos-related disease and that his only asbestos exposure was during his military service, the Board finds that the evidence is, at a minimum, in equipoise regarding the question of whether the Veteran’s current pleural thickening and pleural plaques are related to his military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. The benefit of the doubt will be conferred in the Veteran’s favor and remand is not necessary. The service-connection claim for pleural thickening and pleural plaques is granted. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); Gilbert, supra. 3. Entitlement to service connection for hypertension The Veteran asserts that his blood pressure increases at the time of his headaches. Therefore, he believes that his hypertension is related to his service-connected cluster headaches and that service connection is warranted on a secondary basis. The medical evidence reflects that the Veteran has been diagnosed with hypertension. See, e.g., VA examination, November 2014. The November 2014 VA examiner was unable to link the Veteran’s hypertension diagnosis to his service-connected cluster headaches. Despite the negative VA opinion, the Board’s review of medical evidence indicates that service connection is warranted on a presumptive basis. Specifically, a September 1994 VA treatment record notes that the Veteran had experienced “labile hypertension” at that point for three years. See VA treatment record, September 1994. As the Veteran was discharged from service in March 1990, this record seems to support that his hypertension was diagnosed within approximately one year of service. Although this record does not specify whether the hypertension was compensable within a year of separation from service, the term “labile” seems to suggest some level of uncontrolled hypertension. Affording the Veteran the full benefit-of-the-doubt, the Board will assume that his hypertension was compensable within one year of separation from service. As hypertension is one of the listed chronic disabilities and the evidence suggests that the Veteran was diagnosed with compensable hypertension within one year of separation from service, the Veteran’s hypertension is presumed to be related to service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The service-connection claim for hypertension is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. 4. Entitlement to service connection for genital warts The Veteran asserts that his genital warts began in service and that his current genital warts are related to his in-service diagnosis. Therefore, he believes that service connection is warranted. With regard to a present disability, a May 2014 VA examination diagnosed the Veteran with multiple condyloma to the penis (i.e. genital warts). The first element of Shedden/Caluza is met. With regard to an in-service event, the Veteran’s service treatment records (STRs) reflect treatment for multiple sexually transmitted infections (STIs) in service, including condyloma. See, e.g., STR, August 1987. The second element of Shedden/Caluza is also met. The remaining question is whether there is a medical nexus between the Veteran’s in-service STIs and his current genital warts. As noted above, the Veteran was afforded a VA examination in May 2014. The examiner provided a positive nexus opinion, explaining that the Veteran was treated for multiple STIs in service and that condyloma was one of the STIs for which he was treated. He was, therefore, able to link the Veteran’s current genital warts to his military service. In light of the positive VA opinion and lack of negative medical opinions, the Board finds that the evidence is, at minimum, in equipoise regarding the question of whether the Veteran’s current genital warts are related to his military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. The service-connection claim for genital warts is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. 5. Entitlement to a rating in excess of 60 percent for cluster headaches, on an extraschedular basis The Veteran is currently assigned a 60 percent rating for his service-connected cluster headaches under Diagnostic Code 8100. This includes a 50 percent schedular evaluation (the maximum schedular evaluation possible) and a 10 percent extraschedular evaluation. As the Veteran is already in receipt of the maximum schedular evaluation for his cluster headaches, the only issue before the Board is whether an extraschedular evaluation in excess of 10 percent is warranted. Generally, disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in VA’s Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. However, to accord justice in the exceptional case where the criteria in VA’s Rating Schedule are found to be inadequate, an extraschedular rating that is commensurate with the average earning capacity impairment caused by the service connected disability is warranted. 38 C.F.R. § 3.321(b)(1). Such a rating is warranted when the case presents such an unusual disability picture with related factors such as marked interference with employment as to render impractical the application of the regular schedular standards. Id. When the Board finds that an extraschedular rating may be warranted based on the above factors, it cannot grant an extraschedular rating in the first instance. Anderson v. Shinseki, 23 Vet. App. 423, 428-429 (2009). Rather, it must remand the claim to the Agency of Original Jurisdiction (AOJ) for referral to the Director of Compensation Service (Director). See Thun v. Peake, 22 Vet. App. 111 (2008), aff’d sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board did so in this case in December 2016. In a November 2017 decision, the Director granted an additional 10 percent for cluster headaches, on an extraschedular basis, effective October 1, 2010, and TDIU, on an extraschedular basis, effective June 14, 2012. The AOJ implemented the Director’s decision in a January 2018 rating decision. The Director’s decision is not evidence, but, rather, the de facto AOJ decision, and the Board must conduct de novo review of this decision. Wages v. McDonald, 27 Vet. App. 233, 238-39 (2015) (holding that the Board conducts de novo review of the Director’s decision denying extraschedular consideration). Recently, the United States Court of Appeals for Veterans Claims (Court) reaffirmed that the Board has jurisdiction to review the entirety of the Director’s decision denying or granting an extraschedular rating and elaborated that the Board is authorized to assign an extraschedular rating when appropriate. Kuppamala v. McDonald, 27 Vet. App. 447, 457 (2015). Thun describes the three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular rating for that service-connected disability is inadequate. Second, if the schedular rating does not contemplate the veteran’s level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran’s disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” Third, if the rating schedule is inadequate to evaluate the veteran’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director, Compensation and Pension Service, to determine whether, to accord justice, the veteran’s disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. 111. As the Director’s grant of an additional 10 percent evaluation on an extraschedular basis for cluster headaches did not constitute a maximum grant of the benefit sought on appeal, the Director’s conclusions are reviewable by the Board. Kuppamala v. McDonald, 27 Vet. App. 447 (2015). In Kuppamala, the Court held that the standard for assessing an appropriate extraschedular rating, if any, was whether there was “average impairment in earning capacity” significant enough to warrant an extraschedular rating. Id. at 453-4. The Veteran’s 60 percent evaluation for his cluster headaches recognizes a significant average impairment in earning capacity. There is simply no evidence to support the idea that his cluster headaches alone cause more than a 60 percent impairment in earning capacity. Significantly, in his February 2015 TDIU application, the Veteran indicated that his total occupational impairment was caused by a combination of his service-connected disabilities, including his psychiatric disability and hypertension. As these disabilities are considered to have an effect on his average earning capacity, there is no reason to believe or evidence to support that his headaches alone would constitute more than the 60 percent schedular and extraschedular evaluation that he is currently assigned. The Board acknowledges that it is without set guidance as to any standard for assigning an extraschedular rating for a back disability that has resulted in interference with employment, but which has not resulted in a maximum schedular rating under the Diagnostic Code. As stated above, per the holding in Kuppamala, the standard for assessing an appropriate extraschedular rating, if any, is whether there was “average impairment in earning capacity” significant enough to warrant an extraschedular rating. Kuppamala, 27 Vet. App. at 453-54. However, the Board also acknowledges that it is for the very reason of impact on earning capacity that service connection was established and compensable ratings assigned under the schedular criteria in the first place. See 38 C.F.R. § 4.1 (“Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability”). In this case, although the various examinations have not shown the Veteran to meet the schedular criteria beyond a 50 percent rating, it is clear that his disability results in interference with employment due to frequent and severe headaches that results in severe economic inadaptability. However, there is no evidence to show a higher extraschedular rating is necessary. Without evidence showing a greater than 60 percent impairment in earning capacity, the Board cannot grant an extraschedular evaluation in excess of 10 percent for the Veteran’s cluster headaches. The Board acknowledges that formerly, under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran could be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions failed to capture all of the impacts experienced. Effective January 8, 2018, however, referral of a case for consideration of extra-schedular rating based on the collective impact of two or more service-connected disabilities, as set out in Johnson, is no longer permitted. See Extra-Schedular Evaluations for Individual Disabilities, 82 Fed. Reg. 57,830 (Dec. 8, 2017) (codified at 38 C.F.R. § 3.321(b)(1)). This rule applies to all applications for benefits that are received by VA on or after January 8, 2018, or that are pending before VA, the United States Court of Appeals for Veterans Claims, or United States Court of Appeals for the Federal Circuit on January 8, 2018. Id. As this claim was pending before VA on January 8, 2018, consideration of the collective impact of the Veteran’s disabilities is not available. Accordingly, the Veteran’s claim of entitlement to an evaluation in excess of 60 percent, including on an extraschedular basis, for cluster headaches must be denied. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim of entitlement to an increased rating, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). REASONS FOR REMAND 1. Entitlement to service connection for a back condition with arthritis is remanded. The Veteran claims that his back condition was caused by falls as a result of his service-connected right knee disability. See Veteran statement, February 2018. Thus, he believes service connection is warranted on a secondary basis. Despite the evidence of a current diagnosis, a service-connected disability, and the Veteran’s assertion that the service-connected right knee disability caused the current back condition, no VA examination has been performed. This claim must be remanded to schedule the Veteran for a VA examination. 2. Entitlement to service connection for a left knee condition with arthritis is remanded. The Veteran claims that his left knee condition was caused by falls as a result of his service-connected right knee disability. See Veteran statement, February 2018. Thus, he believes service connection is warranted on a secondary basis. Despite the evidence of a current diagnosis, a service-connected disability, and the Veteran’s assertion that the service-connected right knee disability caused the current left knee condition, no VA examination has been performed. This claim must be remanded to schedule the Veteran for a VA examination. 3. Entitlement to service connection for a left ankle condition is remanded. The Veteran claims that his left ankle condition was caused by falls as a result of his service-connected right knee disability. See Veteran statement, February 2018. Thus, he believes service connection is warranted on a secondary basis. Despite the evidence of a current diagnosis, a service-connected disability, and the Veteran’s assertion that the service-connected right knee disability caused the current left ankle condition, no VA examination has been performed. This claim must be remanded to schedule the Veteran for a VA examination. 4. Entitlement to service connection for a left eye condition, to include a visual scotoma, is remanded. The Veteran was afforded a VA examination to address his left eye complaints in November 2015. The examiner diagnosed the Veteran with suspect glaucoma. He opined that the Veteran did not have a visual scotoma due to his headaches because there was no objective evidence of a visual scotoma. However, he did not provide an opinion on the etiology of the suspect glaucoma diagnosis. There is also no opinion on the additional eye diagnoses identified in a November 2017 VA treatment record. This claim must be remanded to address these and any other diagnoses of record. 5. Entitlement to service connection for vertigo is remanded. The Veteran was afforded a VA examination to address his vertigo complaints in October 2015. The examiner noted the Veteran’s complaints of dizziness and vertigo, but did not diagnose him with vertigo because there were no objective findings of an ear condition on examination or in the reviewed treatment records. However, the examiner did not explain why the Veteran’s subjective reports of vertigo are not sufficient to support a diagnosis. This claim must be remanded to address whether the Veteran has a diagnosis of vertigo and, if so, whether it is related to his active service or a service-connected disability. 6. Entitlement to service connection for OSA is remanded. The Veteran was afforded a VA examination to address his OSA in May 2017. The examiner provided a negative nexus opinion but failed to address the medical literature submitted by the Veteran. He also failed to provide a rationale for his conclusion that the Veteran’s OSA was not aggravated by a service-connected disability. In light of these deficiencies, this claim must be remanded for a new VA examination and opinion. 7. Entitlement to service connection for a sciatic nerve condition is remanded. The Veteran claims that his sciatic nerve condition was caused by falls as a result of his service-connected right knee disability. See Veteran statement, February 2018. Thus, he believes service connection is warranted on a secondary basis. Despite the evidence of a current diagnosis, a service-connected disability, and the Veteran’s assertion that the service-connected right knee disability caused the current sciatic nerve condition, no VA examination has been performed. This claim must be remanded to schedule the Veteran for a VA examination. 8. Entitlement to a compensable rating for calcific tendinitis of the right knee is remanded. The Veteran was afforded a VA examination for his right knee disability most recently in May 2017. However, the examiner failed to address the Veteran’s reports of instability, falls, and flare ups, or to attempt to determine which symptoms were attributable to his service-connected right knee calcific tendinitis and which were attributable to his nonservice-connected right knee arthritis. In light of these deficiencies, this claim must be remanded for a new VA examination. 9. Entitlement to an initial rating in excess of 30 percent from June 27, 2014 to May 16, 2017, and in excess of 70 percent from May 17, 2017 to May 6, 2016, for an acquired psychiatric disorder. There is no evidence in the claims file to indicate that the AOJ issued an SOC in response to the Veteran’s March 2015 NOD with the February 2015 rating decision that assigned an initial 30 percent evaluation for an acquired psychiatric disorder. Therefore, the issue of entitlement to an evaluation in excess of 30 percent from June 27, 2014 to May 16, 2017, and in excess of 70 percent from May 17, 2017 to May 6, 2016, for an acquired psychiatric disorder must be remanded to the AOJ to issue an SOC. See Manlincon, supra. 10. Entitlement to an effective date prior to May 7, 2016 for the grant of a 100 percent evaluation for an acquired psychiatric disorder. Because a decision on the remanded issue of an increased rating for the psychiatric disorder could significantly impact a decision on the issue of an earlier effective date for the psychiatric disorder, the issues are inextricably intertwined. A remand of the claim for an earlier effective date for the grant of a 100 percent evaluation for an acquired psychiatric disorder is also required. The matters are REMANDED for the following actions: 1. Schedule the Veteran for VA examinations with appropriate examiners to address the nature and etiology of his back, left knee, left ankle, left eye, vertigo, OSA, and sciatic nerve disorders, and the current nature and severity of his right knee disability. The examiners must review pertinent documents in the Veteran’s claims file in conjunction with the examinations. This must be noted in the examination reports. With regard to the back, left knee, left ankle, and sciatic nerve disorder claims, the examiner should state whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s current disabilities were caused or aggravated by his service-connected right knee disability. In providing this opinion, the examiner must specifically address (1) the role of the Veteran’s altered gait due to his right knee, (2) the role of falls caused by the Veteran’s right knee disability, and (3) the Veteran’s argument that his weight gain due to his service-connected disabilities and resulting sedentary lifestyle has contributed to his orthopedic disabilities. With regard to the left eye claim, the examiner should state whether it is at least as likely as not (a 50 percent probability or greater) that any of the Veteran’s current left eye disorders (pre-glaucoma, unspecified retinal disorder, etc.) had its onset in service or was otherwise etiologically related to active service or was caused or aggravated by a service-connected disability. In providing this opinion, the examiner must specifically address (1) the Veteran’s contentions that his left eye condition is the result of his service-connected headaches and/or hypertension, and (2) the multiple complaints of left eye pain and tearing in service. With regard to the vertigo claim, the examiner should state whether the Veteran’s subjective complaints of vertigo constitute a diagnosis, even in the absence of objective findings. If the examiner finds that the Veteran has a disorder manifested by vertigo, he or she should state whether it is at least as likely as not (a 50 percent probability or greater) that such a diagnosis had its onset in service or was otherwise etiologically related to active service or was caused or aggravated by a service-connected disability, to include headaches and hypertension. With regard to the OSA claim, the examiner should state whether it is at least as likely as not (a 50 percent probability or greater) that any of the Veteran’s current OSA had its onset in service or was otherwise etiologically related to active service or was caused or aggravated by a service-connected disability, including his headaches and hypertension. In providing this opinion, the examiner must specifically address (1) the February 2014 fellow servicemember’s statement indicating that the Veteran snored, had restless sleep, and fell asleep mid-conversation while in service, and (2) the medical article submitted by the Veteran in July 2013 regarding a relationship between OSA and headaches. With regard to right knee claim, the examiner should identify any symptoms that the Veteran currently manifests or has manifested that are attributable to his service-connected left knee osteoarthritis. All appropriate testing, including range of motion testing, should be performed. The examiner is asked to describe whether pain significantly limits functional ability during flare-ups, and if so, the examiner must estimate range of motion during flares. IF THE EXAMINATION DOES NOT TAKE PLACE DURING A FLARE, THE EXAMINER MUST GLEAN INFORMATION REGARDING THE FLARES’ SEVERITY, FREQUENCY, DURATION, AND FUNCTIONAL LOSS MANIFESTATIONS FROM THE VETERAN, MEDICAL RECORDS, AND OTHER AVAILABLE SOURCES. EFFORTS TO OBTAIN SUCH INFORMATION MUST BE DOCUMENTED. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examination should also record the results of range of motion testing for pain on BOTH active and passive motion AND in weight-bearing and nonweight-bearing. Rationale for all requested opinions shall be provided. If the examiners cannot provide an opinion without resorting to mere speculation, they shall provide a complete explanation stating why this is so. In so doing, the examiners shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. (Continued on the next page)   2. Provide the Veteran and his representative with an SOC regarding his March 2015 appeal of the 30 percent initial evaluation for an acquired psychiatric disorder. They should be advised of the time period in which to perfect an appeal. If the Veteran perfects an appeal, this claim should be returned to the Board for further appellate consideration. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Moore, Counsel